Healthcare Provider Details

I. General information

NPI: 1790976603
Provider Name (Legal Business Name): JILL LYTLE JILL LYTLE, LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2007
Last Update Date: 08/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1454 CLOVERFIELD BLVD SUITE 240
SANTA MONICA CA
90404-2980
US

IV. Provider business mailing address

1454 CLOVERFIELD BLVD SUITE 240
SANTA MONICA CA
90404-2980
US

V. Phone/Fax

Practice location:
  • Phone: 310-857-8776
  • Fax:
Mailing address:
  • Phone: 310-857-8776
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC11652
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: